When Thomas Insel, the director of the National Institute of Mental Health, came out swinging with his critiques of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, a couple of weeks ago, longtime critics of psychiatry were shocked and gratified. Insel announced that that the D.S.M.’s diagnostic categories lacked validity, that they were not “based on any objective measures,” and that, “unlike our definitions of ischemic heart disease, lymphoma or AIDS,” which are grounded in biology, they were nothing more than constructs put together by committees of experts. America’s psychiatrist-in-chief seemed to be reiterating what many had been saying all along: that psychiatry was a pseudoscience, unworthy of inclusion in the medical kingdom. To anti-psychiatrists, Insel’s sudden disparagement of their bitter enemy—a mere three weeks before the A.P.A. released the fifth edition of the D.S.M.—came as aid and comfort, a large dose of Schadefreudian therapy.
But Insel was not saying anything he hadn’t been saying for years. In fact, he wasn’t even the first N.I.M.H. director to say such a thing. Steven Hyman, his predecessor at the post, first began expressing concerns about the D.S.M. more than a decade ago, noting that its categories had been invented primarily to provide a common language for psychiatrists, to ensure that any two doctors, presented with the same patient, would be able to agree on what diagnosis to render, and that the diagnosis would mean the same thing to every other doctor. Diagnostic labels, according to Hyman, had never been intended as more than useful constructs, placeholders that would provide agreement until psychiatry could develop objective measures—presumably when the understanding of the brain caught up with the understanding of the heart or the understanding of viral transmission.
A book full of detailed descriptions of human suffering was not likely to stay within those narrow boundaries. From the time the D.S.M.-III first took the descriptive approach, in 1980, bureaucracies like Insel’s and Hyman’s, which fund most of the mental-health research in the country, began acting as if diagnoses like schizophrenia and bipolar disorder described conditions as real as AIDS or lymphoma, encouraging, if not forcing, researchers to tie their studies to D.S.M. diagnoses. At the Food and Drug Administration, new drug applications tied to D.S.M. diagnoses were placed on a faster (or less slow) track than drugs only tied to symptoms; it was much easier to get approval for a drug targeted to a major depressive disorder than a drug targeted to, say, sadness. In school systems, a D.S.M. diagnosis was an indication that a child had a medical condition that required special services. In courtrooms, expert testimony about a defendant’s mental disorder could affect the disposition of the case. The D.S.M. had been taken, as one of its staunchest defenders put it, “too seriously.” An entire mental-health system had followed the manual down a rabbit hole and into a world that doesn’t really exist. Or, as Hyman put it—and as Insel had long agreed—the D.S.M. had locked psychiatrists in an “epistemic prison.”
The reification of the D.S.M. might not have been more than a philosophical problem, were it not for the fact that, at least in Hyman and Insel’s view, it was beginning to hamstring research. And, indeed, the D.S.M. has frustrated scientists, who note that the most common symptoms of mental disorder—sadness and worry, for instance, or delusions and hallucinations—appear as criteria for many different diagnoses; that many patients can be diagnosed with more than one disorder; and that the few solid findings about mental illness that have emerged from genetic and neuroscience studies indicate that the D.S.M’s categories simply don’t correspond to biological reality. Looking for the neurochemistry of mental disorders that don’t necessarily exist has turned out to be as futile as using a map of the moon to get around Manhattan.
Taking the D.S.M. seriously is not helping psychiatry at all. The pharmaceutical industry seems to be giving up on psychiatric drugs, and people like Hyman attribute the empty pipeline directly to their disenchantment with the D.S.M’s failure to correspond to neurochemical reality. Late in 2011, Insel seemed to be in a state of despair about his profession, which he attributed in part to the D.S.M. “Whatever we’ve been doing for five decades, it ain’t working,” he told me. “When I look at the numbers—the number of suicides, the number of disabilities, the mortality data—it’s abysmal, and it’s not getting any better. Maybe we just need to rethink this whole approach.”
Insel does have a new approach in mind, and he outlined it in his blog post: a research initiative called the Research Domain Criteria. The name invokes an earlier initiative—the Research Diagnostic Criteria—that led off the last effort to revamp psychiatric diagnosis, in the nineteen-seventies; it signals Insel’s intent to start all over again. Rather than beginning with the D.S.M.’s placeholders and then seeking the biochemistry underlying them—which Hyman called a “fool’s errand”—N.I.M.H. would encourage scientists to start with what is already known about the brain’s role in mental suffering and try to build on that to construct an understanding of mental illness. A map drawn this way could not help but reflect the terrain, and Insel wants to encourage researchers to undertake that exploration. But they have been slow to respond. R.D.O.C. has been in the making for at least a decade, and it was officially announced almost three years ago, but N.I.M.H. has not exactly been overwhelmed with grant proposals, and it is hard to find a scientist, even at research centers, who knows much about it. Insel may be handing psychiatrists the key to their epistemic prison, but they don’t seem to be in any hurry to unlock the door.
This may explain the major mystery of his announcement: its timing. Insel has never been a big fan of the D.S.M.; like Hyman, he refused to provide the A.P.A. with any funding for the D.S.M-5. Still, he put up his blog post a mere three weeks before the release of the fifth edition of the D.S.M., a revision that has taken nearly fifteen years, cost the A.P.A. twenty-five million dollars, and garnered strident criticism from all corners, including from loyal psychiatrists. So why would Insel pile on? Of course, it’s possible that he was simply trying to even a score, or otherwise exercise the bureaucrat’s prerogative to throw an elbow. But it is much more likely that Insel wasn’t trying to smack down the A.P.A at all but, rather, to use its misfortunes as an opportunity for R.D.O.C. There may be no such thing as bad publicity, at least not for N.I.M.H., which can offer what no one at the A.P.A, or anywhere else, for that matter, can: a potential, if far off, solution to psychiatry’s increasingly public diagnostic woes—if only the profession can be convinced to abandon the D.S.M. The widespread scorn and scrutiny the D.S.M-5 has encountered may have been an ordeal for the A.P.A., but for Insel they may turn out to be the best advertising that someone else’s twenty-five million dollars ever bought.
Above: Thomas Insel. Photograph by Cliff Owen/AP.